Surgical treatment of gastroesophageal reflux disease

Spotlight on the Linx™ Reflux Management System for the treatment of gastroesophageal reflux disease: evidence and research

BACKGROUND

The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors. In severe cases refractory to such treatments, surgical therapy may be indicated. The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication. In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx™ Reflux Management System. This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity. The aim of this review is to discuss the current literature regarding indications, surgical technique, efficacy, and complications of MSA using the Linx device.

METHODS

A standardized literature search was performed yielding 367 abstracts. After elimination due to duplicates between databases and irrelevance, 96 articles remained. The information found to be significant and non-redundant was included in this review.

CONCLUSION

After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication. With respect to safety, the most common complication of MSA is dysphagia. This often resolved without intervention, but esophageal dilation or device explanation are occasionally necessary. Not fully appreciated in earlier reviews, erosion of the device into the esophagus appears to be the most significant complication of the device after extended follow-up. While very rare, the potentially severe consequences of this phenomenon suggest that the device should be used with some restraint and that patients should be made aware of this potential morbidity. Fortunately, in the few cases of device erosion described in the literature reviewed, the Linx device was easily and safely removed.

[Paradoxical sphincters and cardinal continence function of the gastric fundus]

Gastroesophageal reflux disease is a common disorder in humans and has been treated for the last 67 years using fundoplication. However, treatment results have generally not been satisfactory. Physiological and anatomic findings must be taken into account to improve the therapy technique. In this article, these are described using the example of paradoxical sphincters and the effect of NO signal molecules in the gastrointestinal tract.

Surgical treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a very common foregut disease prevalent worldwide. The prevalence of GERD has risen strikingly over the past decades, causing substantial health and economic burdens. Due to high rates of recurrent reflux symptoms, reoperations and complications, surgical therapy of GERD did not attach enough attention in its early stage. However, surgical therapy for GERD was subsequently revolutionized by the development of anti-reflux surgical techniques and the introduction and popularization of minimally invasive surgeries. Anti-reflux surgery has gradually proved to be a well-documented, effective, therapeutic option for GERD by long-term follow-up studies. In order to improve results and to reduce unwanted effects, surgeons should master the indications of surgery and techniques of anti-reflux surgery. Besides, choosing appropriate candidates and surgical approach is also crucial for outcomes. However, limited by the regional economy and surgeon's skill, the use of anti-reflux surgery is still very limited. The aim of this review is to analyze and discuss the current spectrum of surgical therapy of GERD, and to provide orientation for surgeons in the challenging therapy of GERD.

[Stretch sphincter of the esophagus : Paradoxical sphincter with angiomyoelastic architecture]

The investigations described in this article clearly show that the lower esophageal sphincter (LES) represents a variation of circular muscular occlusive mechanisms found elsewhere in the gastrointestinal tract. The LES is a double layer stretch sphincter that operates in an apparently paradoxical manner: it closes when under stretch but opens when the muscle fibers contract. Impedance manometry studies demonstrate that the entire esophagus is involved in the normal functioning of the esophagus as well as in esophageal disorders. The pronounced elasticity of esophageal tissue is a functional feature that has its basis in the singular architecture of elastic fibers located between the muscle layers. All traditional forms of operative treatment of gastroesophageal reflux disease (GERD) impede the natural functioning of the stretch sphincter to a greater or lesser degree by locking it up. The cause of GERD is mainly by contraction of the esophagus brought about by the cephalad transposition of the stretch sphincter segment into the chest. In a sense this is an incipient axial hernia that frequently remains undiagnosed in the early stages. The operative repositioning of the stretch sphincter segment into the abdominal cavity provides sufficient restoration of the natural topographic relationships to achieve a cure of GERD. Whether this straightforward repair restores the function of the entire esophagus remains to be elucidated. The concept of the stretch provides a good explanation of the pathophysiology of achalasia, a condition in which a paralyzed paradoxical ring sphincter remains occluded. Successful myotomy approaches only split the muscularis propria layer of the stretch sphincter while leaving subepithelial muscle fibers intact that remain paralyzed. This limited intervention provides a good relief of symptoms.